[External] Re: [IMPROVEDX] This is NOT good news for Patient Engagement

Ely, John john-ely at UIOWA.EDU
Thu Aug 9 16:56:50 UTC 2018


Great comments David, particularly your last sentence.  I agree with almost everything you said, but I still think it’s important to ask open-ended questions for as long as you can before giving up and going to closed-ended ones.  Because once you start going down the closed-ended path, you usually can’t switch back to open-ended, and, even if you try, it usually doesn’t work because closed-ended questions are easier to ask and easier to answer.  Open-ended questions usually give you better data and more relevant data, and they can (paradoxically) be more efficient.  Your first question was very open ended but then you got very closed-ended very fast and got stuck asking numerous closed ended questions with the risk of forgetting to ask some important ones.  This is not a big risk for you, but it would be for me (primary care).  So a primary care physician might be better off asking

Tell me more about when you first felt dizzy?

Well what else do you want to know?

Just anything you noticed at the time?

Well I was just dizzy, that’s all.

Silence (Very difficult to do.  Very difficult to maintain rapport and appear supportive.   Easier to do if the patient appears to be actively thinking about what to say next, in which case you absolutely do not interrupt.  Easier to do if you slow down the Q&A tempo so the silence is less jarring.  But if you have to say something, still try to make it as open-ended as you can).

Did you notice anything else besides being dizzy?

Like what?

Just anything else you noticed?

We learn this in medical school and then we get busy and hurried and forget the basics.  And of course the electronic medical record destroyed whatever was left of the basics.

John

From: David Newman-Toker [mailto:toker at JHU.EDU]
Sent: Friday, August 03, 2018 2:51 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: [External] Re: [IMPROVEDX] This is NOT good news for Patient Engagement

I guess I’ll push back a little on this, Mark. I have always been a little concerned that people spontaneously equate “interrupting” with “not listening,” or, worse yet, “not caring.” I can see the logic of these ideas being associated, and I’m sure that some clinicians interrupt their patients thoughtlessly because they have their own agenda and don’t care what the patient is interested in telling them. However, I’m not sure this concept really applies when it comes to good diagnosis. A typical diagnostic encounter in my clinical domain goes something like this…

DNT (asks an open ended question): “So, tell me what happened when you first got your dizziness symptoms?”

Patient: “Well, I was at home this morning. I got dizzy, so my husband called 911. Then the ambulance arrived, and they put me in the back, and then they put in an IV, and gave me some fluids. Then I arrived at the emergency room and Dr. Smith told me I had an ear infection. He gave me a medicine… I can’t remember the name, but I think it started with an ‘M’. Then they admitted me to the hospital because I was too sick to go home….”

DNT (interrupting after ~10-20 seconds of the patient’s story above): “Ok, hold on a minute. Let’s go back a bit to the part where you first got dizzy… Where were you? What were you doing?” … (waits for answers) … “Did you feel unsteady on your feet? How did you get from the hall to the kitchen… Did you crawl? Hold on to the wall?” … (waits for answers)… “Were you sick to your stomach? Did you vomit?” … and so on …

I just think that active listening to the patient’s story means redirecting them to the information that is most pertinent diagnostically… and that often means interrupting frequently with more narrowly-focused or closed-ended questions than the ones you began with. In my view, this is what patients should be looking for in a caring, thoughtful diagnostician. That’s because it is very rare for a (lay) patient to be able to so cogently and concisely tell their illness history that it simply rolls out perfectly over 5-10 minutes while the clinicians politely takes notes for the record in complete silence. I just think there is another side to this issue of “patient engagement” and dialogue.

For what it’s worth, patients can readily tell the difference between someone who interrupts because they want to understand what happened… and someone who interrupts because they don’t care what the patient has to say.

Best,
David



David E. Newman-Toker, MD PhD
Professor of Neurology, Ophthalmology, & Otolaryngology<http://www.hopkinsmedicine.org/profiles/results/directory/profile/0015937/david-newman-toker>
Director, Division of Neuro-Visual & Vestibular Disorders<http://www.hopkinsmedicine.org/neurology_neurosurgery/centers_clinics/vestibular/team/>
Director, Armstrong Institute Center for Diagnostic Excellence<http://www.hopkinsmedicine.org/armstrong_institute/center_for_diagnostic_excellence/>
Core Faculty, Brain Injury OutcomeS (BIOS) Clinical Trials Unit<http://braininjuryoutcomes.com/>
President-Elect, Society to Improve Diagnosis in Medicine<http://www.improvediagnosis.org/?page=BoardMembers>

Johns Hopkins University School of Medicine
Johns Hopkins Hospital; Pathology Building 2-221
600 North Wolfe Street; Baltimore, MD 21287-6921

Administrator: Myriha Montgomery (410) 955-2536; mmontg20 at jhmi.edu<mailto:mmontg20 at jhmi.edu>

Confidentiality Notice: The information contained in this email is intended for the confidential use of the above named recipient. If the reader of this message is not the intended recipient or person responsible for delivering it to the intended recipient, you are hereby notified that you have received this communication in error, and that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this in error, please notify the sender immediately by telephone at the number set forth above and destroy this email message. Thank you.

From: Mark Graber <Mark.Graber at IMPROVEDIAGNOSIS.ORG>
Sent: Friday, August 3, 2018 2:46 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: [IMPROVEDX] This is NOT good news for Patient Engagement

There have been earlier studies showing that clinicians tend to interrupt the patient at the start of the encounter.  At a time when patient engagement and partnership are strongly being endorsed, one would have thought we’d be doing better by now.  I guess not !

Here’s a quote from a new study, attached:  “The patient’s agenda was elicited in 36% of the clinical encounters. Among those in which the agenda was elicited, patients were interrupted seven out of ten times, with a median time to interruption of 11 s.”

Mark

Mark L Graber, MD FACP
President, SIDM
Senior Fellow, RTI International
Professor Emeritus, Stony Brook University, NY
[cid:image002.jpg at 01D42FD4.46DFA0A0]

________________________________

Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>

To unsubscribe from IMPROVEDX: click the following link:
http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1
or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG>

Visit the searchable archives or adjust your subscription at: http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX

Moderator:David Meyers, Board Member, Society for Improving Diagnosis in Medicine

To learn more about SIDM visit:
http://www.improvediagnosis.org/

________________________________

Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG

To unsubscribe from IMPROVEDX: click the following link:
http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1
or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG

Visit the searchable archives or adjust your subscription at: http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX

Moderator:David Meyers, Board Member, Society for Improving Diagnosis in Medicine

To learn more about SIDM visit:
http://www.improvediagnosis.org/


________________________________
Notice: This UI Health Care e-mail (including attachments) is covered by the Electronic Communications Privacy Act, 18 U.S.C. 2510-2521 and is intended only for the use of the individual or entity to which it is addressed, and may contain information that is privileged, confidential, and exempt from disclosure under applicable law. If you are not the intended recipient, any dissemination, distribution or copying of this communication is strictly prohibited. If you have received this communication in error, please notify the sender immediately and delete or destroy all copies of the original message and attachments thereto. Email sent to or from UI Health Care may be retained as required by law or regulation. Thank you.
________________________________

To unsubscribe from the IMPROVEDX:
mail to:IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
or click the following link: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG

Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG

For additional information and subscription commands, visit:
http://www.lsoft.com/resources/faq.asp#4A

http://LIST.IMPROVEDIAGNOSIS.ORG/ (with your password)

Visit the searchable archives or adjust your subscription at:
http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX

Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine

To unsubscribe from the IMPROVEDX list, click the following link:<br>
<a href="http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1" target="_blank">http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1</a>
</p>

HTML Version:
URL: <../attachments/20180809/4150cad7/attachment.html> ATTACHMENT:
Name: image002.jpg Type: image/jpeg Size: 3140 bytes Desc: image002.jpg URL: <../attachments/20180809/4150cad7/attachment.jpg>


More information about the Test mailing list